Angiotensin-converting enzyme 1 (ACE-1) inhibitors. ACE-1 inhibitors are the first-line drug treatments for HF. In two large randomized controlled trials, CONSENSUS (Cooperative North Scandinavian Enalapril Survival Study) and SOLVD (Studies of Left Ventricular Dysfunction), ACE-1 inhibitor therapy was shown to improve survival rates significantly, reduce hospitalization rates, and improve the quality of life of all patients with symptomatic HF.10 An ACE-1 inhibitor should be introduced at the lowest dose and titrated upward on the basis of the patient’s blood chemistries and tolerance of the drug (Table 3).
Beta-blockers. In the COPERNICUS (Carvedilol Prospective Randomized Cumulative Survival) trial and in MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure), the addition of a beta-blocker also improved survival, decreased symptoms, and improved quality of life in patients with mild, moderate, or moderately severe but stable HF.10 Beta-blockers are not appropriate for and should be avoided in patients who have class IV HF or are experiencing an acute exacerbation. The drug should be initiated at the lowest dose and titrated to the target dose as tolerated. Of note, in COMET (Carvedilol or Metoprolol European Trial), carvedilol was substantially more beneficial than the short-acting metoprolol.11 Table 4 describes dosages for these drugs.
Angiotensin receptor blockers (ARBs). ARBs are used as an alternative treatment option for patients who cannot tolerate an ACE-1 inhibitor as a first-line modality. For patients who continue to experience symptoms after being optimized on ACE and beta-blocker therapy, an ARB can be added as a second-line treatment to relieve symptoms (Table 5).10
Aldosterone antagonists (AAs). AAs may offer some additional benefit for patients with moderately severe or severe (NYHA class III/IV) HF; however, there is no evidence to suggest that adding an AA to the therapy of a patient who does not have NYHA class III/IV HF will result in any further benefit.10 Dosages are listed in Table 6.
Other medical therapy options. The use of digoxin has not been shown to improve survival rates.10 In the presence of atrial fibrillation, digoxin can be added after the beta-blocker dose has been maximized and has failed to control the heart rate adequately.
Diuretics are commonly used for the management of HF; however, they are given solely for symptom relief and improvement in quality of life. Diuretics have not been shown to have any benefit in improving the survival rates of patients.
The combination of hydralazine and isosorbide dinitrate has proved beneficial when added to ACE/ARB therapy in African American patients with NYHA class III or IV HF.12 The recommended starting dose of hydralazine is 37.5 mg, which is titrated upward to 75 mg three times daily. The starting dose of isosorbide dinitrate is 20 mg and is titrated to a target dose of 40 mg three times daily.